Response to college students’ mental health needs: a rapid review

ABSTRACT OBJECTIVE To present strategic options to support the adoption of mental health strengthening policies for university students in the field of health, to be implemented by university institutions. METHODS Rapid review, without period delimitation, with searches carried out from May to June 2020, in 21 sources of bibliographic data, including gray literature. The following keywords were used: mental health, students and university. The selection process prioritized systematic reviews of mental health interventions for university students in health care courses, and also considered other types of review and relevant primary studies. RESULTS Forty-five studies were included: 34 systematic reviews, an evidence synthesis, an overview, a scope review, three narrative reviews, three experience reports and two opinion articles. The evidence from these studies supported the development of four options: 1) to establish and support policies to strengthen the mental health of students in health care courses; 2) to integrate mental health care programs, expand their offer and facilitate access by students; 3) to promote educational programs and communication strategies related to contemporary psychic suffering and its confrontation, so that students can get to know the services and resources and identify strengthening practices; 4) to continuously monitor and assess the mental health needs of students in health care courses. CONCLUSIONS The options are challenging and require universities to establish institutional commissions to implement a policy to strengthen the mental health of university students in the health area, with the ability to recognize the different health needs, including manifestations of psychic suffering ; to integrate the university’s internal actions with each other and with the services of the Unified Health System; to implement and monitor the actions that make up the mental health policy.


INTRODUCTION
Mental health problems are a global concern and the complex phenomenon of suicide is considered a public health problem 1 because it is the second leading cause of death among young people aged 15 to 29 years 2 .
The object of this review is the mental suffering of university students, a group in which the phenomenon is associated with university sociability and family distancing 3,4 , as well as academic overload and an increasingly competitive environment generated by competition in the labor market [5][6][7][8] . For graduate students, the probability of suffering from depression and anxiety is six times greater than for the general population 9 .
A study conducted by the World Health Organization among university students from eight countries found that 35% of students had positive screening for at least one of the common mental disorders evaluated, reasons for suffering and impaired academic performance 10 .
An integrative review of the Brazilian literature found a variation from 34% to 49% in the prevalence of psychological distress among university students 11 . A survey conducted with 136,000 undergraduates, 14% of the total number of students from 53 Brazilian federal universities, found that 80% had emotional difficulties in the previous year, 58% related to anxiety, 45% to feelings of discouragement/lack of will, 32% to insomnia/sleep disorders, 23% to feeling helpless/hopeless, 21% to feelings of loneliness, 13% to eating problems and 11% to fear/panic. The results also identified 6% of responses related to the idea of death and 4% to suicidal thoughts, corresponding to almost 60,000 students who thought about death and 40,000 with suicidal ideation 12 .
In Brazil, studies that focus on health and education policies aimed at attention to mental suffering in university students mainly focus on students from courses in the health area 7,11 . The complexity of the health care object carries feelings that cause psychological distress 13 for students starting practical activities, due to insecurity and proximity to pain and death 3,11,14,15 . In nursing courses, exposure to stressful factors can occur during the initial adaptation period; throughout the course, due to insecurity and the complexity of care; in the end, due to the concern with entering the labor market and the demands of the profession 16 , and the traditional evaluation processes 17 . Undergraduates in the health area are more susceptible to psychological and emotional distress, due to the link to environments with high emotional demand, such as contact with pathological processes, like communicable diseases that generate fear of acquiring diseases, in addition to the fear of making mistakes and the feeling of impotence in the face of some diseases and death 3,14,15 .
It is noteworthy that mental problems starting in the university period can also affect professional life, which reinforces the importance and need for the development of institutional coping strategies, with the university environment being considered fertile for the conduct of actions that promote mental health 3,4,14,18 .
Based on these considerations, this study aimed to present strategic options to support the adoption of institutional policies to strengthen the mental health of university students in the field of health, to be implemented by university institutions.

Study Design
It is a rapid review, recognized as a type of study capable of providing high-quality evidence in a timely manner to support decision-making and the improvement of health policies, as per the guide of the World Health Organization (WHO) (2017 ) 19 . The elaboration process is guided by the systematic review method, with adaptations, aiming to produce summaries of the best available evidence, in a timely manner, to meet specific demands 19 . This review was carried out in 90 days, a modality of the McMaster Health Forum Rapid Response program a , and developed in two stages. First, the problem was delimited through project team meetings and preliminary bibliographic surveys, which guided the stage of definition of search strategies and publications survey, to retrieve studies that presented or evaluated strengthening actions, programs and policies of mental health of university students, in order to compose a list of plausible interventions to be implemented by university institutions.

Eligibility Criteria
Priority was given to studies of mental health interventions for university students, from systematic reviews (SR), with or without meta-analyses, overviews, evidence syntheses, and other types of reviews, published in English, Spanish and Portuguese. There was no restriction regarding the year of publication of the studies.

Search and Selection of Studies
Searches were performed from May to June 2020, using the terms students, university and mental health in 21 data sources in the literature: PubMed, Health System Evidence, Social System Evidence, Epistemonikos, McMaster Plus, Health Evidence, Embase, ASSIA, Campbell, Cochrane, ERIC, JBI, CINAHL, Scopus, PsycInfo, LILACS, CAPES Theses and Dissertations Catalog, Sociological Abstract, OpenGrey, PEDro, Social Service Abstract. Search strategies were set out for each data source. Box 1 shows an example of the search strategy in PubMed.
Subsequently, publications indicated by researchers or identified in supplementary searches were integrated to synthesize evidence not dealt with in the included reviews. The selection process showed that the contingent of publications on individual therapeutic interventions, of the cognitive-behavioral type, was very numerous (48), which would require extra time for data extraction. In this case, an additional filter, more rigorous and specific in the selection, was established, excluding reviews that did not provide the countries where the primary studies were carried out or the search date, and those that did not present a meta-analysis.

Data Extraction and Assessment of the Methodological Quality of Included Studies
The extraction was performed in an Excel spreadsheet and included items such as author, year, study objective, intervention, results, limitations, proportion of studies from low-and middle-income countries, as classified by the World Bank 20 . The SRs were assessed for methodological quality using the AMSTAR 21 tool and classified as low (score 0 to 3), moderate (4 to 7) or high (8 to 11) quality. Non-systematic reviews and primary studies were also assessed for methodological quality using specific instruments: JBI Critical Appraisal Checklist for Text and Opinion Papers 22 ; Critical Appraisal of a Case Study 23 ; Scale for the Quality Assessment of Narrative Review Articles (SANRA) 24 ; JBI Critical Appraisal Checklist for Systematic Reviews and Research Synthesis 25 ; Criteria for Evaluation of Experience Report 26 and Evaluation of the Methodological Quality of Evidence Synthesis for Policy 27 . They were classified as low (up to 30%), moderate (30% to 60%) and high (60% to 100%) quality.

Shortcuts Used
Six reviewers (CBS; EMGG; FCAC; MCB; LC; TST) performed the stages of study eligibility, data extraction and methodological quality assessment; as indicated in rapid reviews, the study did not need a pair of reviewers. Selection questions were resolved by consensus and extraction was verified by a seventh reviewer (TY). Key message 3. Based on: introduction of stress management programs into the medical curriculum, changes in duration, curriculum type, and pass/fail grading system 42 ; interprofessional discipline on contemporary youth problems, with emancipatory potential for university sociability 43 ; curriculum changes implemented in early periods of courses to increase social skills and resources to address personal or academic problems 44 ; mandatory course on mental health in modern society and a course in mind-body medicine, taught to first-year medical students, as well as structural changes in the curriculum 32; group stress management, training in relaxation skills and cognitive-behavioral techniques in the Nursing course to prevent course dropout 45 ; structural, systemic and cultural changes that can impact medical education 46 . Although training programs in early mental health    care are considered effective to improve knowledge in the area, few are the curricula that integrate them, being found in courses in the health area in only three countries 47 .
Key message 4. Supported by interventions to improve access to minority mental health services, such as crisis services information hotline, presentations of experts and family members and individuals with mental health problems 33 . The organization of conferences on inclusion, equality and diversity in university education provided an opportunity to discuss homophobia for academics, students, LGBT activists and other Nigerian groups 47 .
Institutional guidelines for situations of violence and discrimination based on gender and sexual orientation, and protection measures so that victims of violence are not harmed in their training, such as comprehensive care for victims, investigation and rapid responses to reported cases 48 . Key message 5. Based on the concept of integration of services and resources offered by the university to those of the Brazilian Unified Health System (SUS), as integrated strategies can enhance the supply and access to services, preventing the university from taking responsibility alone for the care of students 29 .
Key message 6. Supported by evidence on individual non-pharmacological treatments for stress, anxiety and other signs and symptoms of psychic suffering. Analysis of mindfulness intervention and other behavioral therapies showed satisfactory results 46,50-56 . For depression, psychological therapies were highlighted as the most effective 57,58 . Mindfulness interventions and stress management programs were effective. Compared to pharmacological treatment, non-pharmacological interventions had moderate beneficial effects on depressive symptoms in nursing students. Short-term interventions moderately relieved depressive symptoms and depression 54 . Psychoeducational interventions produced significant effects in reducing symptoms of anxiety, stress, psychological distress, among others 59 . Interventions with music, physical exercise, yoga, tai chi, among other activities, were effective in preventing common mental health problems, with medium-term programs having better effects than short-term ones 52 . Counseling and mindfulness interventions contributed to stress management and reduction [60][61][62] . Brief interventions with individual focus of mindfulness were shown to be limited in reducing levels of anxiety, depression and stress in medical students with suicidal ideation; most of the evaluated interventions were offered during the pre-clinical years, and there is evidence that the problems become more expressive during the period of incursion into clinical practice 46 . Analyses of interventions to reduce alcohol consumption, such as face-to-face and internet programs, have shown the need for further research to identify more promising approaches 63 . Individual therapies aimed at changing behavior showed an effect in reducing alcohol consumption 64,65 . Satisfactory results were observed from the brief, single-session intervention for high alcohol consumption, but future research should examine what would be the effective duration of this intervention 66 . Regarding the improvement of eating habits, face-to-face interventions, media approaches and nutrition labeling were positive. Physical activity promotion interventions should carefully consider personalized interventions. In the case of sleep, cognitive behavioral therapy showed greater effects compared to hygiene interventions 63 .

Key message 7.
Based on e-health type interventions. A small effect on academic performance, depression and anxiety was reported in the analysis of interventions such as: web platform, with optional use of a mobile application; program with personalized feedback; opportunities for personal training integrated into the university's online course platform; intervention with thematic modules such as goal setting, personal strengths and career plan; integration of knowledge about oneself with meaningful goals; intervention based on acceptance and commitment therapy; computerized expressive writing intervention to report academic fears 67 . Multidirectional intervention, with feedback through a computer program, showed a positive result on the intention to smoke cigarettes, but not marijuana. Brief web-based or computer-based personalized feedback programs were not effective in reducing or preventing marijuana use 68 . Virtual interventions such as feedback to assess current levels of alcohol consumption and interactive games have shown potential to help reduce alcohol consumption 69 . Indicated interventions (with pre-existing problems) were advantageous over universal interventions (without pre-existing problems) for outcomes such as depression, anxiety, stress, social and emotional skills 70 . Internet interventions to improve mental health, well-being, and Box 2. Options and key messages.

Options for policies Key message
Option 1: Establish and support a policy to strengthen student mental health in the health area, capable of sensitizing and responding to the identification of mental health needs.
1. Organize a mental health committee within the courses in the health area, with the objective of discussing the main problems that affect students and supporting them in deciding on the best way to face the challenges they are facing; 2. Develop activities to reduce the stigma related to mental health, as well as to promote cultural improvement, well-being and sociability, which can contribute to a change in mentality and strengthen students in the search for improvement in mental health; 3. Propose curricular changes in courses in the health area of the University in order to provide critical elements for students to understand the relationship between mental health and society, detect problems, seek help and support colleagues who are experiencing situations of psychic suffering; 4. Integrate programs and activities to combat racism and prejudice against LGBTI, quota students, and other forms of discrimination against students, as well as programs and activities to support student retention.

Option 2:
Integrate and expand the provision of mental health care programs and provide access to them for health students.
5. Formally integrate mental health care services available at the university through a collaborative network of health services offered on and off campus, integrated with SUS services, developing a flow of comprehensive care for university students; 6. Expand health promotion activities and non-pharmacological interventions in mental health services offered by the university; 7. Adopt an assessment program, using virtual technologies, as an application to assess the mental health of university students for referral to appropriate health services.

Option 3:
Promote educational programs and communication strategies for students in the health area, regarding psychic suffering in contemporary times and ways of coping, to ensure that students know about services and resources, identify welcoming practices and can access them.
8. Promote communication and make available, in an accessible way, information from all health services and support groups for students focused on mental health, through a cell phone application and links on the university's official websites; 9. Encourage discussions about current youth problems and stimulate critical debate about racism, prejudice and all forms of discrimination that affect students' mental health.

Option 4:
Continuously monitor and assess the mental health needs of students in health courses.
10. Implement a mental health monitoring program in courses in the health area, for the planning and implementation of actions; 11. Create a support network from a mentoring program to monitor students.
The first option summons managers of healthcare courses and universities to action and decision-making, showing the need to establish institutional policies, in contrast to specific actions and isolated initiatives. This decision requires the constitution of a working group that: prepares a plan for implementation, with clear and objectively delineated purposes and goals; provide the development and monitoring of the results of projects and implemented actions; and offer permanent support to students and managers, for the effectiveness and continuity of the process. These actions must not lose sight of the confrontation of the stigma intrinsic to the theme of mental suffering, nor the perspective of dealing with the theme of mental health across the curriculum, in order to enable the student to develop critical analysis and the understanding of the roots of problems faced. The studies point to the need to include teachers and other workers in the discussion process, improving the debate and favoring proposals for joint confrontation, with institutional commitment to sensitive issues that cause suffering, such as racism, prejudices against LGBTI and quota holders, and other forms of discrimination 48,[75][76][77] . This first option requires deep structural, paradigm and practice changes from the institutions, and its implementation in the medium/long term demands dedication of time and effort from those involved.
As a second option, in the short term, universities and courses in the health area can make an effort to identify existing actions and available services, in order to integrate them and formally offer the university community information and access to this care network. Institutional protagonism is essential, organizing programs and actions linked to the university's internal care network and SUS (Brazilian Unified Health System), to the detriment of isolated actions. The need to expand the offer of these services is included, pointing out two paths: expansion of therapeutic activities so that they are not restricted to pharmacological interventions, and inclusion of information and communication technologies to assess suffering, then guiding and directing students to appropriate services. Telehealth is a useful tool to increase access, and mental health is a pioneer in the use of these technologies 67,71,72 . The university, which often researches these innovations, has a duty to incorporate them into the care routine of its community 16,17 .
Option 3 focuses on the need for institutional development of educational strategies that illuminate contemporary mental problems, with emphasis on those arising from prejudice and attitudes of discrimination, and the ways in which they are faced. The implementation of educational strategies and debates with the entire academic community should focus on issues related to forms of discrimination and their relationship with psychic suffering. This debate can bring up demands and strengthen the intra-institutional support network 31,33 .
Option 4 shows that coping with psychic suffering requires permanent monitoring of mental health actions, as well as their inclusion in the institutional agenda, with the creation of support networks for students and the involvement of the entire academic community. In this option, tutoring programs and monitoring of cases of mental suffering among students are identified, within the units, which demand coping and welcoming strategies, joint reflection on the identified problems and possible referrals, follow-up and monitoring of the processes 28,43,73 . The institution can create integrated work mechanisms with health services, family and professors, to facilitate the student's therapeutic process, given that the university environment is excellent for the implementation and monitoring of actions to promote mental health 4,19 .
Mental health needs are shaped by the forms of work and life inherent to the class inclusion of students and their families 78 . A university policy to strengthen university students in the health area, which takes into account the strategic options shown in the literature, must recognize the social differences and the different manifestations of students' psychological suffering, in the implementation of collective monitoring mechanisms.
In health courses, the conditions for admission and permanence, as well as the occurrence of mental health problems, are unequal. An analysis of the occurrence of depressive symptoms among students from different courses shows a higher prevalence of these symptoms in nursing courses, followed by dentistry and medicine courses 79 . These courses are attended by graduates from heterogeneous groups from the point of view of class insertion, considering social indicators such as the level of education of father and mother and type of institution (public/private) where the student attended high school 80 .
Recognizing that the university environment can be, in part, the cause of mental suffering is a fundamental step in transforming the university into a healthier environment.
To cope with psychological suffering, UFSCar constituted a commission that proposed a mental health policy b that provides for the integration between SUS services and the services and resources offered by the university, in order to develop actions aimed at: improving mental health; prevention of injuries; the provision of care to consequences of these possible injuries, such as suicide attempts; and the reduction of harm caused by the problematic use of psychoactive substances. It also provides for actions to collect, analyze and manage data to generate indicators and monitor the phenomena of psychological distress and evaluate the actions taken. It also indicates the establishment of mechanisms to understand the relationship between the teaching/learning processes and psychic suffering, as well as the development of the UFSCar Code of Ethics, and protocols for preventive actions and for the care of situations of violence 81 .
The options presented here, for coping with the psychic suffering of students, require the involvement of the entire academic community, with a marked commitment from the faculty, which, however, is under intense pressure and psychological burden 82 . In the Brazilian context, this is compounded by scientific productivity demands to professors linked to graduate programs, which generate suffering and illness 83 .
The subjective precariousness felt by the university professor, who is permanently concerned with responding to the high productivity demands, translates into a feeling of isolation and abandonment 84 . This precariousness operates less objectively as compared to that which affects workers from outsourced companies and temporary professors, as they are subjected to informal work and the loss of fundamental, social, labor and social security rights. Therefore, they see their security concretely shaken.
Graduate students have also been the object of studies related to stress in mental health 9,85,86 , as a consequence of pressure. There are pressures caused by the obligation to fulfill academic demands; by the difficulty in maintaining a balance between academic and personal life; by uncertainties about the future 85 ; and by the need to achieve the academic productivity goals required by research development agencies 86 .
Therefore, the implementation of responses to mental health needs within universities finds the context of pressure for productivism, which imposes on professors, students and the entire set of workers the achievement of institutional goals based on quantitative international standards of academic excellence. The deepening and amplification of neoliberalism in higher education needs to be made explicit and recognized as a process that responds to the aggressive global capitalist expansion, shaped by the market logic 87,88 . In the Brazilian case, the quality of knowledge production is questioned in the face of the current competition for excellence 89 .
It is urgent that universities make commitments to the public cause, genuinely democratic, for and with society. Since neoliberalism is ideologically pedagogical, in the sense of teaching consent and reproducing domination, the answer, also of a pedagogical nature, must radically oppose it, constituting a transformative pedagogy, whose purpose is freedom and emancipation 90 .